1. PTSD Medications Kendra Saxvik, PharmD, BCPP
Clinical Pharmacy Specialist, Mental Health

2. Diagnosis: DSM 5 Criteria
Criterion A: Trauma/Stressor
Criterion B: Intrusion Symptoms (Re-experiencing)
Criterion C: Avoidance
Criterion D: Negative alterations in cognitions or mood
Criterion E: Alterations in arousal and reactivity

3. Biological Aspects Neurotransmitters
Higher circulating levels of norepinephrine
Increased reactivity to α2-adrenergic receptors
May help explain somatic symptoms
Greater activation of sympathetic nervous system
Alterations in brain structure
Amygdala and hippocampus
These areas involved in fear responses
Fault y memory processes presumed to be dependent on hippocampus may be involved in intrusive memories
Gradus, 2014

4. Psychological Aspects
Response to fear is both biological and psychological
Influenced by subjective interpretations
Traumatic events threaten sense of safety
Biological response perpetuates fear and threatened feeling
Overwhelms coping and leads to avoidance
Gradus, 2014

5. Therapy

6. Psychotherapy First line treatment across most guidelines
Several recommend medications should not be used first line, but in instances where therapy has failed or unavailable
2013 NHMRC – Australia
2005 NICE – UK
2013 WHO
2017 APA (draft)

7. Psychotherapy Exposure Therapy Cognitive Processing Therapy
Stress Inoculation Training
Imagery Rehearsal Therapy
Psychodynamic Therapy
Dialectical Behavioral Therapy
Hypnosis

8. Pharmacotherapy

9. SSRI’s Selective Serotonin Reuptake Inhibitors
Mechanism: inhibit serotonin uptake in CNS, resulting in more available serotonin
Target symptom clusters: all
Re-experiencing
Avoidance
Negative cognitions
Hyperarousal

10. SSRI’s Many side effects resolve within a week Common side effects:
Upset stomach
Sexual dysfunction
Serious side effects
Suicide Risk: Black Box Warning under 24 years old
Serotonin syndrome (fever, stiffness, agitation, tremor)
Time to Effect
6-8 weeks at a therapeutic dose

11. SSRI’s Generic Brand Dosing Range Citalopram Celexa 10-40 mg daily
Escitalopram
Lexapro
5-20 mg daily
Fluoxetine*
Prozac
10-80 mg daily
Paroxetine*†
Paxil
10-60 mg daily
Sertraline*†
Zoloft
mg daily
* = most studied
† = FDA approved

12. SNRI’s Serotonin Norepinephrine Reuptake Inhibitors
Mechanism: inhibits reuptake of serotonin and norepinephrine in the CNS
Target symptom clusters: all
Re-experiencing
Avoidance
Negative cognitions
Hyperarousal

13. SNRI’s Many side effects resolve within a week Common side effects:
Increased blood pressure
Upset stomach
Sexual dysfunction
Serious side effects
Suicide Risk: Black Box Warning under 24 years old
Serotonin syndrome (fever, stiffness, agitation, tremor)
Time to Effect
6-8 weeks at a therapeutic dose

14. SNRI’s Generic Brand Dosing Range Desvenlafaxine Pristiq 50 mg daily
Duloxetine
Cymbalta
mg daily
Venlafaxine*
Effexor
37.5 mg – 300 mg
* = Most studied

15. Mirtazapine Brand name Remeron
Mechanism: increases serotonin and norepinephrine in CNS, exactly how is unknown. Also antagonizes histamine receptor
Target Symptoms:
Re-experiencing
Hyperarousal
Time to Effect
6-8 weeks at a therapeutic dose
Sleep: within a few nights

16. Mirtazapine Common side effects Serious side effects
Sedation (we take advantage of this!)
Increased hunger
Weight gain
Dry mouth
Serious side effects
Suicide Risk: Black Box Warning under 24 years old
Serotonin syndrome (fever, stiffness, agitation, tremor)
Generic
Brand
Dosing Range
Mirtazapine
Remeron
mg qhs
(at night)

17. Prazosin Time to effect: Brand name Mini-Press
Mechanism of action: Old blood pressure medication working by α blockade and relaxing smooth muscle
Target Symptoms
Re-experiencing (specifically nightmares)
Hyperarousal
Time to effect:
A couple weeks of titration

18. Prazosin Common side effects: Serious Side effects: very rare
Dizziness
Orthostatic hypotension
Lethargy
Serious Side effects: very rare
Syncope
Hypotension
Generic
Brand
Dosing Range
Prazosin
Mini-Press
1 – 25 mg qhs
(at night)

19. Atypical Antipsychotics
Not effective as monotherapy
May be helpful as adjunctive, so may see occasionally
Target symptom clusters
Re-experiencing
Hyperarousal
Common Side Effects
Sedation
Dizziness
Weight Gain
Serious Side Effects
Metabolic Syndrome
Involuntary muscle movements

20. Atypical Antipsychotics
Generic
Brand
Dosing Range
Aripiprazole
Abilify
2-30 mg daily
Lurasidone
Latuda
mg daily
Risperidone
Risperdal
1-6 mg daily
Quetiapine
Seroquel
25 – 800 mg nightly
Olanzapine
Zyprexa
2.5 – 30 mg nightly

21. Benzodiazepines
Mechanism: Bind to GABA receptor, increasing the receptors activity and inhibiting CNS reactivity
Contraindicated in PTSD
Studies have demonstrated harmful
Inhibit memory formation as well as are disinhibiting
When used prophylactically, increased rates of PTSD
Target symptom clusters
Do not work for any core symptom cluster
Will see used for insomnia, anxiety, irritability
High risk of chemical dependency in PTSD (using as avoidance)
Braun, 1990
Gelpin, 1996
Mellman, 2002

22. Benzodiazepines Common Side Effects Serious Side Effects Disinhibition
Dizziness, unsteadiness
Depression
Sedation
Cognitive effects
Falls
Rebound anxiety
Serious Side Effects
Physical dependence and abuse
Severe withdrawal (tremor, anxiety, seizures, death)
Risk in overdose: can be fatal in combination
Drug Interactions

23. Benzodiazepines Generic Brand Equivalent Dose Dosing Range Alprazolam
Xanax
1 mg
0.25 – 1 mg QID
(4 times daily)
Clonazepam
Klonopin
0.5 mg
0.25 – 2 mg BID
(2 times daily)
Diazepam
Valium
10 mg
2-10 mg BID-QID
(2-4 times daily)
Lorazepam
Ativan
0.5 – 2 mg TID
(3 times daily)

24. Summary
VA/DoD Guidelines, 2010

25. References
VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. National Center for PTSD. Veterans Administration. October, 2010.
Gradus, J. Epidemiology of PTSD. National Center for PTSD. Veterans Administration. Updated Jan, 2014.
Braun P, Greenberg D, Dasberg H, Lerer B. Core symptoms of posttraumatic stress disorder unimproved by alprazolam treatment. The Journal Of Clinical Psychiatry [serial online]. June 1990;51(6):
Gelpin E, Bonne O, Peri T, Brandes D, Shalev AY. Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatry 1996; 57 (9):390-4.
Mellman TA, Bustamante V, David D, Fins AI. Hypnotic medication in the aftermath of trauma. J Clin Psychiatry2002;63:
Micromedex Clinical Database.
Guideline Development Panel for Treatment of PTSD in Adults. Clinical Practice Guideline for Treatment of PTSD in Adults. American Psychological Association. Feb, 2017.

26. Questions?